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ELIZABETH A. NEVILLE
TOWN CLERK
REGISTRAR OF VITAL STATISTICS
MARRIAGE OFFICER
RECORDS MANAGEMENT OFFICER
FREEDOM OF INFORMATION OFFICER
Town Hall, 53095 Main Road
P.O. Box 1179
Southold, New York 11971
Fax (631) 765-6145
Telephone (631) 765-1800
8outholdtown.northfork,net
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
APPLICATION
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SOUTHOLD WASTEWATER DISTRICT
CONSTRUCTION or ALTERATION PERMIT
CESSPOOL or SEPTIC TANK
Residential @$10 /' or Non-Residential @$25 _
Application Na3052>
Permit No.
Applicant Name
Applicant Mailing Address
PECONIC CESSPOOL
P. O. BOX 972
MATTITUCK, NEW YORK 11952
Septic Tank_or Cesspool~
Brief Description of Proposed Construction or Alteration ~" ~~,t:zn.--(
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Location of Proposed Construction/Alteration:
Owner of Property: 'f..".../ ~.-h~
Owner Mailing Address: 1J 7[) /l14..A.AAA... Ik.. I
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Owner Property Address: S L-o...c.
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Nameandphonenumberofcontactperson ...c:: ~ {,.Ji'-~Ff'-(}(,Sg
Tax Map No: Section /0 If Block OS- Lot -37
Cross Street !.;,4j M....te:- ~
I'i'OTE: LOCATION MAP MUST BE SUBMITTED WITH APPLICATION. NEW
.CONSTRUCTION REQUIRES SURVEY WITH HEALTH DEP AlQ'MENT APPROVAL
/ Si~;;::!; /Iu-;/# Date
Received by: /r;;.
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FRED MARKHAM
875 MASON DRIVE
CUTCHOGUE
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